Summary Report for FSPSAs Initiated During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 689 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 0.511111 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 3.452381 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 3.963492 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 8.669047 $190.2800 $21.9500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.366667 $9.3600 $25.5300
EXIT -EXIT EXIT ASSESSMENT 5 5 125.071429 $6253.5700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 1.422221 $106.6600 $74.9900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 11 3.383332 $253.7400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.216667 $16.2500 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 6 12.764286 $957.3200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 13 15.536507 $862.2700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.011111 $0.8300 $74.9300
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Subtotal (Total Children Is Unduplicated) 25 44 167.441267 $8650.2900 $51.6600
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.522222 $26.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.766666 $88.3300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 31 37 26.005555 $1300.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 3.000000 $75.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 95 117 147.536509 $7376.8300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.311111 $7.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 4.533334 $226.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 3.133334 $156.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 78.752382 $3937.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 338 462 1987.385729 $19873.8500 $10.0000
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Subtotal (Total Children Is Unduplicated) 344 639 2252.946842 $33069.1200 $14.6800
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Total 689 2424.351601 $41719.4200 $17.2100
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Number of Children (Unduplicated) With at Least One Authorization 352